A 19 year-old Army active duty white male, presented to the optometry clinic with sudden onset of decreased vision and a constant area of central blurry vision in the right eye for 1½ weeks. The patient noted similar, less prominent symptoms in the left eye. Ocular examination revealed multiple circumscribed, flat, cream colored lesions in the posterior pole, originating from the macular area with presentation in the right eye greater than the left eye (OD>OS). Fluorescein Angiography (FA) demonstrated late staining of the lesions. A diagnosis of APMPPE was made. Final visual outcome was 20/25 –2 OD, 20/20 OS. No further ocular or systemic complications were noted.
A 19 year-old Army active duty white male, presented to the optometry clinic with a sudden, painless onset of decreased vision, and a constant area of central blurry vision the right eye for 1½ weeks. The patient noted similar, less prominent visual symptoms in the left eye. The patient had not previously sought care for this condition, and had a negative history for trauma, headache, and recent illness. The patient, however, was a new Army recruit and had received multiple vaccinations prior to onset of symptoms.
Best-corrected visual acuity was 20/150–1 OD, 20/20 OS. Pupils were equal, round, reactive to light with negative relative afferent pupillary defect (RAPD). Extraocular muscle examination revealed no restrictions OD, OS. Amsler grid revealed distortions superiorly with no view of the center dot OD, and no distortions or scotomas OS. Slit lamp examination (SLE) revealed clear lids and lashes, conjunctiva, cornea, and lens OD, OS. The anterior chamber was deep and quiet OD, OS. The iris was flat and intact OD, OS. Angles were grade 4 nasal and temporal OD, OS. Intra-ocular pressures were found to be 11mm Hg OD, OS.
The dilated fundus examination (DFE) revealed flat, distinct optic nerve head appearance with cup to disc ratios of 0.15 round OD, OS. Multiple, circumscribed, flat, cream colored lesions were located in the posterior pole, originating from the macular area OD>OS. The lesions in the right eye included the fovea (with negative foveal reflex or -FR), and the lesions in the left eye circumvented, but did not include the fovea (+ FR). The peripheral retina was flat and negative for holes or tears OD, OS.
The patient presented with signs and symptoms characteristic of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE). Plan/Education
The patient was referred to ophthalmology for confirmation of diagnosis and FA. The following tests were ordered: purified protein derivative (PPD) skin test, antinuclear antibody (ANA), antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), angiotensin-converting enzyme (ACE), rapid plasma reagin (RPR), complete blood count (CBC), erythrocyte sedimentation rate (ESR) that day to rule out any underlying systemic disease. A home amsler grid was given to the patient for self-monitoring of increased distortion. The patient was informed to return to clinic as soon as possible if sudden vision changes occurred. Ophthalmology Consult
The patient reported no improvement or change since the last evaluation. The test results were: - PPD, - ANA, - ANCA, - RF, ACE of 35 (normal 9-67), RPR non-reactive, CBC with all results in normal range, ESR of 4 (normal 0-10). Best-corrected visual acuity remained 20/150 OD, 20/20 OS. Intra-ocular pressures were 13 mm Hg OD, 12 mm Hg OS. The SLE was unchanged since the last examination. The DFE was similar to last exam, except the lesions appeared gray with some pigment mottling, and there were no new lesions. FA revealed late staining of lesions with pale edges and a pseudo-podal configuration.
The diagnosis was APMPPE versus Serpiginous...